Northern Communities Health Foundation Public Lecture

Northern Communities Health Foundation Public Lecture

well good evening everybody welcome my
name is professor Benjamin Karl I’m in the newly commenced executive Dean of
the Faculty of Health and Medical Sciences it’s great to see you all here
I want to start by acknowledging and pay my respects to the Kaurna people the
traditional custodians whose ancestral lands we gather on tonight we
acknowledge the deep feelings and attachment and relationship with a
gallant leader of the country we respect and value their past present and ongoing
connections to the land and their cultural beliefs it’s a real pleasure to
welcome you here tonight to the annual northern communities Health Foundation
lecture this is actually my fifth day it’s executive Dean and my first public
event so it’s a real thrill to see you all here now before the lecture and we
introduce our our visiting professor and guest of honor I’d like to enjoy
introduce the chairman of the northern communities Health Foundation mr. Lane
pain who’s going to be presenting the Darracq
through an early career research or awarded professor Karl thank you very much for
for the invitation and formally on behalf of the northern communities
Health Foundation board members welcome you and thank you for coming to this the
annual nch of public address this year to be presented by this is the 16th
annual public lecture and here’s the 16th time we’ve had a visiting professor
sponsored by the foundation the program started in 2007 the visiting
professorship program is one of several programs the foundation supports for the
university in addition to the vp program we do support research projects and
prizes for students PhD top-up scholarships and other opportunities
that we have to support the work of the university the foundation was
established in 1998 following the closure of the northern community
hospital but some of you may remember was based on Prospect Road right next to
Prospect home the financial viability of the hospital came in through a
significant question at the end of 1997 and it was decided to close the hospital
and from the asset the sale of the assets the money that was left over from
that process was invested in a trust and the foundation was established with
the objectives of promoting the health status of people in the northern
communities of Adelaide and the board since that time has been involved in
quite a number of projects both of the University and the the with the
community some of our community projects have been in the area of mental health
which is a particular area of interest that we are concerned tonight and we
have a current project at the Playford council the play for suicide prevention
programme in that the foundation is supporting this time coming back to the
University programs one of the programs that we are very proud to have
established is the direct through an early researcher it’s valued at $5,000
and is awarded to a fear somebody in a field of Derek’s own nomination somebody
who is excelling in the research activities and this has enormous
potential for research into future years this year the early research award was
given to somebody in the field of renal medicine it’s a prestigious award
Derek fruit was the executive dean of the medical school for
but we have come to love dairy as a member of the foundation having been
vice chairman for a number of years and chairman of our girls committee so
tonight it’s a great privilege to announce that the winner of the Derek
through an award for 2019 is dr. Sebastian stead and I bought professor
frohnen emeritus professor Derrick Freeman to
come and present the ward to Sebastian finally one of the things that the board
the northern communities Health Foundation has achieved this year is the
establishment of a Research Foundation to augment the mchm the board has over
the years since its inception given our in the order of 1.5 billion
dollars for research projects and activities of awards that referred to
earlier not any substantial amount of money when you consider that when the
hospital was facing closure it was predicted that it would have lost about
a million dollars in the following year so spent caught up the positive and a
pleasing result that’s come from the ashes of the hospital if you mark so
this year the board has determined that it now needs to grow to be over for more
projects and increasingly larger projects particularly those
with the University so a research foundation has been established website
has been established and we are ready to grow the foundation so if you have any
spare cash any time then you may wish to remember the website address down there
WWWE CHF commed are you not quite at the moment the first donation will be
received by the foundation and the change of general meeting in November by
mr. Frank Agostino a problem businessman he had like who’s committed to donate
five thousand dollars per year for the next five years to establish the
research foundation so we’re looking forward to a growth in the foundation
and to be able to bring even more visiting professors to Adelaide to share
their knowledge such as a visiting professor mr. Knight and visiting
professors to be introduced by our executive day professors Benjamin wing
Thank You Lee Congrats rational capacity there is there is no greater thrill than
seeing young people with a broad future research doing well so it’s that’s a
great great honor Sebastian in the math group to see you receive it so this
evening we hear from dr. harrell Cutler from the United States visiting
professor and courtesy of the northern community
Foundation and he is an internationally recognized expert in the treatment and
research into trauma induced stress it’s got a number of colleagues and
collaborators here in Adelaide in South Australia but also in Australia North
Broadway and it’s a real honor to have him here with us tonight
to talk about his work they received is documented from downstate medical center
in Brooklyn New York and studied psychiatry trained in psychiatry and
Yale University he joined the faculty of Chuuk University in 1984 at the same
time you joined the Veterans Affairs Department which is a really really big
deal in the United States healthcare system I mean since that time he’s as I
said developed an international reputation both as a clinician as
someone who treats trauma injury stress but someone who researches and tries to
understand the causes and and ways to treat trauma induce stress he was the
founding chair of the post traumatic stress disorder practice guidelines task
force of international society from traumatic stress studies and the first
author of the resultant guidelines in 2014 he was appointed as chief mental
health consultant to the United States Veterans Affairs Veteran Affairs
Department and acting secretary under deputy before retiring in June 2018 dr.
Cutler continues to serve on the Jeep faculty
and faculty a number of national international
organizations as I said it’s a real honor and a thrill to have you here with
us tonight there will be time for questions after the presentation Toofan
a please join me in welcoming I seem to be on the air all right good
Thank You Benjamin Thank You Len and and my thanks to knowing communities Health
Foundation in many ways the history and mission of the health foundation are
mirrored in the same issues that I hope to address here today and again if I
start to talk like a native New Yorker I am one so if I go too fast let me know
but we’re here to talk about clinical and public health approaches to the
mental health and well-being of service members veterans and their families
integration I also want to take a moment to thank doctors Jackman Elliot Paula
Davidge and also and also Josie gray who made this visit possible and did so much
to help me prepare so let’s let’s take this forward
I’ve already been introduced again 31 years as a psychiatrist working in
clinics in our Department of Veterans Affairs when I started out the world war
two and Korean War veterans and prisoners X persons of war of those
words that I work with were actually younger than I am today which is a
frightening idea for me I went on eventually to become a national policy
lead for the Department of Veterans Affairs
so anything that went right but usually anything went wrong in the area of
mental health or was on the cover of some newspaper was my job to respond to
in some way and in the years I’ve lived in North Carolina it’s a state in which
every branch of our military has a major base the largest army base in the United
States is in North Carolina about 90 miles from Russell the second largest
Marine base with forces rotating into Iraq and Afghanistan every six months
and and then rotating again is is about two
hours to our East and it is it is what they call themselves every state in the
United States constants of the most military friendly state in the nation
but neuron is certainly one of the most military intense States with one out of
ten people in our state being a veteran and that would translate to probably
another two out of ten people in our state living under the same roof with
one it is part of our lives every day back in 2000 I chaired the Department of
Veterans Affairs Under Secretary Special Committee on
PTSD which was actually created by Congress to make sure that the VA was up
to snuff on clinical care benefits research and education and the year 2000
thinking about PTSD was largely a retrospective job we were looking back
at Vietnam and just barely paying attention to World War Two in Korea
because PTSD was considered a Vietnam problem by 2001 of course with the
attacks on the World Trade Center and the Pentagon now PTSD was a prospective
problem knowing that we’re going to war we have never taken the concept of PTSD
and applied it prospectively how do you prevent PTSD when you’re sending a whole
generation off to war and we have now been at war for 18 years so we have
people who are just barely born when the attacks of September 11th happened who
are now already veterans of Iraq and or Afghanistan it’s it’s an historic
occasion to be in and it’s really what I want to talk to you about today so I
should introduce the Department of Veterans Affairs Casino again to
paraphrase George Bernard Shaw Australia in the United States our two nations
separated by a common language and I very likely will use phrases
you’re familiar with in a way that means nothing at all in terms of the normal
context so our Department of Veterans Affairs has three components the
Veterans Health Administration that’s the healthcare part messed apart that I
work in the Veterans Benefits Administration which gives college
grants sends people to college my own father as the first person whose family
ever go to college and that’s because he was a veteran it endorses mortgages for
veterans so they have a place to live insecurity can build wealth over their
lifetime and we also run the world’s largest cemetery program the the
National Cemetery administration so we’re very large with over 380,000
employees were the second largest Department of the United States and with
a an annual budget overall that’s approaching three hundred billion
dollars a year if we drill down to our clinical services we run a hundred and
seventy major medical centers across our nation not just in the in the
continental United States but in places like wom we have a hundred and
seventy-five thousand and seventy four community-based outpatient clinics we’ve
built in the last 15 years realizing that many people couldn’t reach our
brick-and-mortar hospitals because our nation is a good size not as big as
yours I think but but a good size and it’s hard to access those big medical
centers we also have 300 vet centers and I was lucky enough that when I started
as a resident psychiatry one of my first clinical supervisor still a friend today
art blank was just leaving for Washington to become the first director
of the vet centers he had been a psychiatrist in Vietnam during the war
and art took on the mission of running these storefront operations staffed for
the most part by combat veterans paid for by the VA but not looking like the
VA very informal and very few ties no medicines prescribed not clinics but
staffed by psychologists social workers peer counselors and a drop-in place
where veterans and their family members who anyone who had ever served the
combat area of operations could just drop in and get absolutely free services
whether or not they were enrolled in a VA hospital system it was welcoming it
was local it was peer led for the most part and it’s a model that I want you to
consider because we’ll come back to it a bit later along these same and since
then they’ve got a t-mobile vet centers so the Vet Center program can now go to
a natural disaster or a place like September 11th the Pentagon and park
right outside and actually run a clinical operation with satellite
telemetry to take everything back to the mothership if if needed further VA is
hired at this point over 1400 Peer Support Specialists these are people who
are veterans with a lived experience of a mental health problem and they’re
becoming really essential to us and our ability to talk to veterans in their own
language again not already wants to talk to a psychiatrist I know that’ll
surprise you but but to have somebody who’s really been there and talks your
language and and and it has some of the same needs and experiences you have
really makes a difference in providing access you can build a hospital and I’ve
seen this happen right next to somebody’s house and they’ll never go
there but if you have a peer support
specialist a very good chance they’ll only go but that’s take and finally
we’ve created more more telephone lines than anyone will ever remember be able
to track but our Veterans Crisis Line has tracked hundreds of thousands of
calls from veterans and is capable of locating a veteran on a mountaintop in
Tennessee and sending emergency help them if necessary thinking about VA care if you follow the
American news at all we’re always getting beaten up and sometimes we need
to get beaten up it keeps us on our toes but the VA provides mental health
according to our national candidate of science engineering medicine at a
quality that’s actually superior to other public and private providers we
run the largest mental health system in the nation maybe in the world and we’re
the biggest employer psychiatrists psychologists social workers in the
United States there are nine million enrolled veterans at our system of the
20 million living US veterans six million use our health services annually
and one in four will use a mental health service in any given year
and it’s not the same one in four by the way if the general public had acts in
the u.s. at least had access to mental health services at the level that
veterans have veterans have much more access in the general public I am sure
they would be using one in four abusing mental health services per year – it’s
pretty much what we predict the average population is going to have in the
average year in 2017 word and 1.7 million veterans receive care at a VA
mental health program which is doubled since 2006 this largely because we
provided more capacity since 2006 not because veterans needed more help since
2006 nearly a third of all these patients
receive care from mental health providers who are kool-aid located and
part of the teams of our primary care clinics in the old days primary care doc
says you I think you might be depressed I’m gonna give you appointment in a few
weeks to see if a psychiatrist come on back and the veteran leaves saying I’m
not taking another day off from work I’m not driving 90 miles and I don’t really
want to see a psychiatrist anyway now the provider says look you see they be
having some problems of depression I’m gonna walk it down the hall introduce
from my friend and colleague and he’s going to see you now and this has been
incredibly helpful in providing real access for mental health services and
doing it proactively instead of after people are really in trouble now I mentioned that in 2000 I became
the co-chair Frank that was the only co-chair of the Undersecretary of
Special Committee on PTSD that happens a lot seems to happen to me a great deal
but anyway one of the things we decided to do is we needed to have data on what
was happening with these new people coming back from Iraq and Afghanistan
and so would the Undersecretary of help and I was in the room when he called
this other fella when we got the head of our epidemiology service in the VA to
begin quarterly reports pulling together tons of data and it is great to be a
giant national entity which has tons of data and people who can analyze it
so we began reporting quarterly in the second quarter of in 2002 and this
quarterly reporting continued through 2015 and followed over a million
veterans coming in and out of Afghanistan the data indicated service
members veterans and veterans encountered significant problems
engaging with our system as well as DoD systems many of these people were
reservists so they’re in the military when they’re called up in the reserves
and they’re veterans as soon as they get back and then they go back in the
military when they call the Beginner’s reserves so we had a lot of data on DoD
folks as well at Department of Defense almost 60% of the veterans by our last
count are our 2015 had received a mental health diagnosis and I don’t think
that’s at all unusual in a combat area because these include everything from
moderate anxiety to PTSD PTSD being the single most common diagnosis of people
who rotate through combat area but depression substance use by the way
tobacco abuse and I’m talking like smoking like a chimney Dwarfs all other
forms of substance abuse they don’t even reported anymore in
mental health because it makes the members look bad but but in fact if you
want to save lives you deal with tobacco abuse early on and what we did find
though is that as we got better reaching out to people for instance we created
what’s called the post-deployment health assessment and then our data showed us
that people don’t seem to have a mental health problem or want to talk about it
when they first come back so six months later we’re now giving the
post-deployment health reassessment and at that time their wives where husbands
have usually said if you don’t tell your doctor you’re having this problem I’m
out of here and then they tell us the truth and and and then they fill out the
form and they come into our system and we begin to offer them services as of
2003 we were beginning to realize we needed a new approach because even then
into 2005 more than half the veterans coming back from Iraq and Afghanistan
we’re reporting problems but they weren’t coming in for help you know it’s
up to them they don’t have to come if they don’t want to but we didn’t think
that was very helpful for our nation or for them as individuals or for their
families so we began to develop new kinds of programs including a VA
research education and clinical centered devoted to what we call deployment
mental health as opposed to PTSD PTSD is real it’s very important however
it’s too narrow a lens to understand what really happens in deployment there
are many other kinds of problems many of which are not mental health disorders at
all but extremely destructive in life with a veteran or their family
further in 2005 we had the first meeting of our local States group of North
Carolina governor’s workgroup tell you a little about that because I’m very proud
of that and and in our efforts working on this I think we’ve learned some of
the principles that I want to talk to you about today for the first thing it’s
a big tent as opposed to our VA which is this junk of an agency which drills down
and tells people what they’re going to do which is never Pleasant for people we
just decided we pulled as many partners together this started with six people
two of us from the VA and four people from our governor’s off
sitting around a table in the state government office saying what are we
going to do too inviting as many people as we could possibly imagine might be
interested in this issue to a very large kickoff meeting and this began a set of
meetings in 2005 that continued monthly to the present every single month since
2005 we’ve been reading and the meetings are now shared since I left I chaired it
for about 11 years but after I left it it did better it’s
now chaired by senior VA health and benefits leads for our region as well as
senior state government people like the head of the Department of Commerce you
know about jobs and employment issues it regularly includes over 5,000 virtual
attendees every session plus about 75 to 100 in the room and it’ll take on any
issue at all vaguely related to veterans and it allows possibilities for
presentations by anybody who has an even a remote interest in veterans to give
you example of people who train service dogs and just bring them as a charity as
opposed to the larger organizations that do it or a lawyer may be my favorite we
have NASCAR I know you have car racing because when I turn on the news here I
see it we have the American version of car racing NASCAR and one of the pit
crews decided they would start hiring veterans and not just any veterans they
would go to our PTSD inpatient unit of one of our psychiatric hospitals and say
we want the people who failed your program the people you think are never
getting out of here and they give them a job any job they want it might be
polishing cars it might be fixing engines it might be doing advertising
and marketing for their business and they have proven to a man and woman that
those people actually rejoin life and get better in their symptoms if you give
them something meaningful which they enjoy doing and which gives them a sense
of efficacy and value in the world which is a very important theme you know
again you can look at PTSD through a lot of lenses and you need a lot of lenses
to understand a problem like this biological psychological and social but
it’s wonderful when someone who is not too worried about being a psychiatrist
is just trying to help it takes in this case a social lens and rebuilds people
from the bottom up and shows that it can be done and and it can be done so let’s
see then in the next seven years we had a further shift of vision and mission
based on these experiences assuring that servicemembers veterans to academies are
recognized and have access to military culturally competent as well as
clinically competent care whenever and wherever they seek care it’s just a big
problem the u.s. we have a very strange health system and Peter goes had a go at
me about this and he’s absolutely right our VA system is a single pair system
much like your national house but most Americans don’t have that they all have
different insurance policies with a dizzying array of services and many are
sort of none there’s non access to mental health it
may stay in writing you have access but in fact you have no access to mental
health care and and and and so many people are totally puzzled and give up
quickly which makes the insurance companies happy if it doesn’t help us as
a society our system is designed to be a no wrong door system what the governor’s
workgroup created is not just a bunch of people who present to each other but
literally thousands of people who know each other at this point years into it
and when they hear about a problem they say I can’t fix that but I know somebody
who can and they pick up the phone and call them and that person fixes the
problem for this individual and then everybody learns something and then the
next person it’s an expert it’s a facilitated pathway it’s highly
individualized but it has to be because no two veterans are the same even if
they serve in the same place at the same time their experiences in the same
their needs will not be the same now all this led to this idea of communities of
care and a friend of mine who is a Department of Defense psychiatrist you
Koza we work together on Sesame Street I know you have Sesame Street here too we
created a series Seve really was a prime mover and I got to be a a kibitzer a
series for military children the first was about a parent who goes away for a
long time in comes home the second was a parent who comes home with visible or
invisible injuries and the third was on the death of a parent a few years later
Steve called me up and said look we’re putting together this special issue of a
journal and again I can give you these slides and you can get the entire
journal online if you like the future of children and I want you to write a
chapter called on communities of care and I said Steve that’s great what are
communities of care he said I thought you would know that’s how I summarized
what you were talking about with the governor’s focus and everything else you
know the governor’s work group said okay well we’ll figure it out and then he
assigned his colleague army colonel Rebecca Porter to work with Ian
and-and-and and together we wrote this this chapter and it calls for a public
health approach that goes beyond clinical models that focus on
servicemembers veterans their families as individuals and harnesses the
strengths of communities which surround them and the fact is again I’m a doctor
I’m trained you welcome to my office I examine you I make a diagnosis I
Institute of course of treatment you get better or you don’t get better and I’ll
keep working with you until you do get better or you fire me one of those
things many patients I followed for 30 years in the VA working with them and
many of them were a great deal better and some keeping them alive was was an
accomplishment but a public health approach is a very different thing and
that’s what we’re going to be diving into it requires making servicemembers
veterans and their families visible in civilian settings where they’re not
recognized we did a study first from the VA and then it was replicated by the
RAND Corporation command as a giant think tank that hires
itself off the government but can do any research they feel like doing there
they’re very well positioned and Rand replicated our study at a much higher
level and showed that the vast majority of civilian clinicians and clinicians in
public health programs and in private health programs never take a military
history never asked the simple question have you or someone close to you served
in the military a lot of doctors and other kinds of clinicians don’t think
that’s a relevant question you know why would I want to get into that although
it’s one the doctor said to me look I’m a small businessman as a doctor patient
walks in my office I got 15 minutes with that patient if I asked him if he served
the military he starts crying then the 15 minutes are up he doesn’t get any
treatment I never even find out what he was there for so why would I want to ask
that question but I and and I can understand his position but I think even
that were motivated by the more common concern that I wouldn’t know what to do
with the answer so if I knew you were a veteran what would that mean to me I
don’t know anything about it and this is where the drive to develop military
culturally competent care military culture is a true culture of its own we
spend a lot of time learning about other cultures I really appreciate that we
spoke of of the native people whose land there were we’re standing on today but
we don’t talk about military culture and yet in the United States I mentioned 20
million veterans another 15 million people living with them or under their
rules if you were to ask the question have you or someone close to you served
in the military one out of six Americans would answer yes that to me is very
relevant and and I think frankly it’s our duty as members of our of our nation
to be asking that question I don’t the numbers are very different here in
Australia you have about 58,000 people in your military we have 2.5 million you
have about 675 yes 675 thousand veterans only about
only a small proportion of whom are actually enrolled in your veteran’s
health system but I still think it would make a lot of sense and I think it’s the
right thing to do and I’m a great fan of the right thing to do in our article we
began to envision you know to try to frame all this though in in in written
language and this idea of that the spectrum of care for these folks has to
go beyond the health system into schools into colleges we pay people to go to
college but we don’t look after them when they’re at college into workplaces
through we have Employee Assistance Programs I imagine you do to educating
those people educating personnel staff so when there are problems in the office
it might be the veteran is agitated and can’t stay at their desk for long
periods of time where it might be the wife or husband of a veteran who’s
coming back the veterans just come back home or is coming back home and the kids
are having problems and things aren’t working and don’t fire that person
understand their issues and find ways to support them religious institutions
research has shown that service members and veterans were having problems with
issues related to combat are five times more likely to tell a congregational
leader about that problem than they are to tell a mental health professional so
we need to reach out to those people plus the focus of local communities and
many of our veterans like many of your veterans are rural are highly rural it’s
the church that runs that community it’s the public school that knows if the kids
having problems and before you simply say put that kid on Ritalin you might
ask the question do they have a parent who’s stationed overseas or who came
home missing an arm or whose parents are getting divorced related to stress that
happened while they were separated for long periods of time those would be good
things to know and to act upon so the core idea and this is
bred out of the article is communities of care are defined as complex systems
that work across individual family community military state and national
levels of organization to promote health and well being an effective community of
care can be measured by its public awareness of service members its ability
to recognize their needs and support them in community settings and the ease
with which service members veterans and their families can access resources and
services and by no means reserved to medical systems medical systems are
totally inadequate to manage what really is a a public health problem and that’s
a problem public health issue let’s put it that way
because a lot it’s just normal I mean you know you you go into a con that area
for a year and people are shooting at you your family members at home and and
all kinds of things are going wrong in it the washing machine explodes and the
kids are having trouble at school and you know between the two of you when you
get back together it’s a normal that things not feel very normal and this
needs to be understood and there are many people who could help with this if
was left to psychiatrist everybody being in a lot of trouble one of the programs
we developed for all of this is something called painting a moving train
that’s actually a quote from one of our Marine generals who said trying to catch
up with these wars that were in is like trying to paint a moving train we
created a series of over 50 day-long trainings for healthcare professionals
where we train them 50 times and got a national grant from a group not unlike
the northern communities a Health Foundation through which we train 20,000
providers nationwide I have to tell you that that seemed like quite an
accomplishment at the time but I found in the years since we did this 20,000
providers is a drop in the bucket it didn’t move the needle at all it really
didn’t change what was expected of health providers in America
and and so that’s why we’re going bigger with this kind of a model but through
this program we did it make the effort to connect civilian support systems with
Department of Defense and VA programs from everything to mortgages College
training vocational training employee assistance homelessness programs etc we
also took the list of attendees we had thousands of attendees and turned it
into with their permission a comprehensive database Oh with with
Google mapping to their offices and pictures from space of their offices and
all of their special interests and military and whether they a sliding
scale and whether they in which courses they had taken it shown interest in and
put that on the web so that search can make referrals so that school officials
could make referrals so that people could self-refer so the kids could look
it up for their parents family well-being is critical to the capability
in the military you have the family force and veterans initiative here the
national Vietnam veteran readjustment study which we did in the United States
frankly it was done because Congress wanted to close our Vet Center program
in the 1980’s thinking well it’s ten years after Vietnam and that you they
must be over it by now it was the largest epidemiologic study
ever done of a single mental health issue in this case PTSD and one of his
most important findings is that the strongest predictor of whether a person
from who served in Vietnam continue to have PTSD or ever had PTSD was the level
of perceived social support from their family it wasn’t even the real social
support in their family but if the veteran believed that their family had
their back they were less likely to ever get PTSD or continue to happen
State and you know for all the interesting things about the biology of
PTSD which floods the journals this fine thing ethic is you know at least equal
to any of them and what are we doing to put this finding into effective action
to help people not enough yet and then you consider that thanks to my friend a
colleague Becky Porter they wrote this of a communities of care article with
the 57% of everybody in the mellah she just said I look up how many people in
the military are the children of veterans 15 57 percent of everybody in
the United States Army which is our largest force by far are the children of
veterans so we have a military dynasty you know Plato predicted in his Republic
said you might want to have a military a segment of your community and what are
we doing about the intergenerational aspects and again I want to become that
pathologizing children of veterans we have an opportunity to build you know a
much more resilient force if we pay attention to how these kids are being
raised and are you know are we taking a best advantage of the fact that we have
their parents and we could be doing something for these kids probably not
we’re not making taking advantage of that at all and military families face
predictable stressors the deployment cycle you know we stopped talking about
just PTSD and looked at deployments stress and there are different stresses
at different points and the deployment cycle includes pre deployment when a
parent first finds out they’re going overseas and they get notice awhile in
advance then they usually go away for very long training before they actually
deploy and during that time there’s a lot of stress then they actually deploy
and by the way they almost never end up doing what they trained to do but that’s
just the other military but but that they spend that time overseas long
separation most people who serve overseas will tell you yes people were
shooting and they yes things kept above dangerous yes I was blown up but I
really feel sorry for my spouse at home because they had all the hard work they
really and and they believed this they really do and I think it’s it’s often
true in many ways is fast at home has a harder time and then there’s the post
deployment we and so many families break up and so
many children run into significant problems other stresses include starting
a new family where or every two years on average our military members move to
another city or another country through their postings or transition out of the
military which is something dr. danovich and I are working on now well with all
that experience I decided go to Washington and fix everything and you
can imagine how well that went but in addition to responding to the
crisis of the day what was some newspaper article in a in a newspaper I
wouldn’t read myself but somebody wrote an article what I’d have to be called
under somebody’s office and explain this and then write something about it and do
something about it I became increasingly aware of the history of the VA and and
the fact is in the aftermath of World War one our VA was conceived of not as a
bunch of hospitals but as a population health system which not only provided
high-quality care that was culturally competent in clinically competent for a
military population that’s a special set of problems but which also focused on
prevention resilience health and well-being across American society and
that vision had eroded the people running our hospitals thought of
themselves is just hospital directors and if they had all the things that went
in the hospital that was enough and and that isn’t enough it doesn’t create
these communities it doesn’t focus on resilience
it doesn’t employ a population health perspective and in fact the biggest
problem had to deal with I mean the Secretary of Veterans Affairs would come
back to the White House a couple of blocks away and say well the president
told me I’m being judged on how many veterans are committing suicide and the
fact is of the 20 United States veterans and military members who die every day
on average by suicide which fine number 14 of those veterans are not
in our system at all they are not patients in the VA health system so the
fact is a lot certainly came home to me that I could do the best job in the
world I could train the best people we could have the best equipment and all
the space it didn’t matter if 14 out of the 20 people who most needed us never
came to us and to me that is the ultimate proof that you need a
population health system just to reach these people let alone cheese that that
dynamic so we need a population health approach which meat meets its target
audience wherever they might be even if they never came to our health system and
I want to say a word about that so again we start with the veteran and we’re
supposed to be a veteran centered and veteran driven program but as I say the
veteran often isn’t with us and then we take that veteran and we build a health
system around it with these elements hospitals clinics hall lines and the Vet
Center program I talked about all of which are outstanding I’m very proud of
all of them but which as I say have proved to be insufficient and yet most
of our administrators think oh I doubt that I’ll just polish the floors and
people who want to come improve the food but a population health system requires
reaching into other places colleges as I mentioned work places
legal system so many veterans end up in our legal system for various reasons and
by the way the most common reason by far our crimes associated with homelessness
because these people have fallen through every social web that we could build
they they lose their jobs they drop out of school their marriages fall apart
it’s about a ten-year tailspin into homelessness and and so the homeless
systems veterans organizations are a place to
reach out because they’ll go there before they come to us congregations as
I’ve mentioned so that those are places to reach and we started to engage with
them but then we began to think about special populations which includes a
special forces pop group which is a you people’s native americans just as you
have here with the aboriginal communities Native Americans the United
States serve at the highest rate of any population in the US and have the
highest rate of PTSD largely because they were underprivileged before they
got into the military they go back to underprivileged neighborhoods where they
haven’t got a chance of getting a job where substance abuse is rife and and
they really haven’t got much of a chance than either so you’re reaching into
those groups and creating new opportunities women veterans women
veterans in the u.s. are more likely to be homeless than male veterans the rate
of suicide a woman among women veterans has increased I think now six-fold and
the reason being it’s I’m sorry six-fold above the above the average American
woman that suicide and the reason is they use firearms firearms are 90
percent lethal in a suicide attempt the usual means by which women in America
commit suicide is more like ten percent effective in terms of lethality so women
veterans are dying at a much higher rate and so we need special average and rural
veterans but then the real population health issue there are a lot of people
in this system I’ve shown you structures or venue abstractions your individual
people and it’s beyond my power point skills but the fact is at least in the
u.s. about three out of every ten dots here would be a veteran in their family
members in the nation of well and then they’re not just the people in our
system it’s the people all over our nation in a nation of over 300 million
people if 1% of those people were to help us in
reaching out to veterans we would have a workforce much bigger than anything the
VA could ever muster and this I think ultimately is the key and I say that
because at the in the aftermath of World War one it wasn’t because government
wanted to do this job or new attitude job it’s because citizens just like this
forced government to do this job it’s because if you enlighten people reached
out to the American citizenship got their attention and said you must do
this and that’s why government did it and that’s where we are today but that’s
a flame that has to be rekindled and in fact my retirement is largely to work on
exactly that so just imagine if within this group I don’t know if you can see
my cursor even a few of these people were to form little groups sitting
around their kitchen tables to say you know something we all go to dr. X down
the street dr. X has never asked any of us that we serve in the military we’re
gonna go there and say to dr. X I want to ask everybody in your practice I want
my local hospital ask everybody I want my employer to ask everyone if they
served in the military I want my public school so identify military children and
honor them and their families and also reach out to them and help in any way
possible if people did whatever was so the low-hanging fruit for them it would
amplify our ability to honor and assist service members and veterans logarithmically so these joint efforts
are now new joint efforts in underway in Australia Canada in the US and again
Paula has really spearheaded this to develop population health strategies
based on process and working with the theory that she developed looking at the
moment of separation from the military and the huge change in identity that
comes when you go from a culture that is altruistic others centered I will do
this for my buddy not for myself to a world where respected to be
self-centered and individualistic and frankly you lose the support of that
community it’s a tremendous shock to go back into the civilian world and a great
place where we begin to intervene essentialist is a focus on well-being as
opposed to sickness and disability and to jump ahead at least this idea of
whole health and wealth and this is a concept that is used here
in Australia and very similar terms to what we use but to give you a sense of
well-being well-being isn’t about a sickness system it’s about a health
system it’s it involves aspects like are you sleeping are you eating are you
employed oh are you having good relations with your family and friends
do you have ways of coping with stress and anxiety and ultimately the question
we’re trying to add some veterans and this is a national initiative in the VA
what matters to you in life not how do you feel but what do you want to be
around for what do you want to do and if you can’t do it because you’re having
problems how can we help you overcome those problems and not just in a health
arena but how could your boss help you how can your the clergy help you how can
your life help you or your husband how can you help your kids do what they want
to do we’ve actually developed in our VA a an index for this a new validated
measure called the well-being inventory which by the way is free of charge
everything our Department of Veterans Affairs does is in the public domain and
which we’re beginning to use in Australia we’re hoping to is and hope to
use in other nations as well and compare our military and their families on
well-being as a measure it’s not enough to say do you have PTSD or don’t you and
then send the people who don’t home are you living a good life in your terms and
this is the way to find that out and when we find out people aren’t figuring
out what’s wrong and then figuring out which systems will help them these are
just direct quotes actually from what we send to veterans and on our website and
I’ve given you a website there but the bottom line is we’re trying to turn the
VA into a community of care but only one small hub in a much larger
of care and that is the basic idea and I’ll stop there and have still left you
a few minutes to ask questions were or correct things thank you very much all
right short answer I don’t believe you could be trained easily in resilience
the US Army created a perfect call a comprehensive soldier fitness and I
think it was an immense waste of time if the idea was to model what really strong
people do and then train people to do it and the biggest problem with it is if
you fail to feel that you were succeeded then it was your fault and I think that
just compounded the sense you know there are really hard things in the world and
servicemembers know that better than most people I don’t think that’s the aim
but they even be resilient what resilience really means is you take the
blow and you come back and I think we need to build that mindset as opposed to
I will make you so strong in advance that nothing is going to hurt you I
think that was an awful idea but I’m 3,000 miles away I can say I was struck whether they’re coming to
mind about resilience and the perception of family support they came back so my understand which is the visit of
American military history is that the Vietnam Wolves of the sea American
Commission was here at strengthen and the veterans were tourists they felt
unsupported yes the Afghanistan Iraq still controversial
but it seems to me that that was a difficult area especially inside the differences in the rights of actually there is no difference in the
rate of PTSD between Vietnam veterans which lifetime is about 30% and the last
time we redid the National Vietnam veterans readjustment site we made it
into a longitudinal study it was about 10% and we see pretty much the same in
Iraq and Afghanistan but it is true that people now are getting more support
during the Gulf War the first Gulf War a lot of the people coming back said we’re
not that Vietnam stuff and they distance themselves they also distance itself
from talking about it or doing anything about it if they did have the problem
because again they felt like they were the standouts I must be weak I was
supposed to be stronger by the way I also want to correct one thing an iPod
just because I’m probably worried about the time warden some of you are that I
do believe resilience is something that can be developed
I do believe Steve Steve Sasson was mentioned earlier and Dennis Charney two
old friends actually and they’ve written some wonderful works on resilience
resilience is an important concept resilience can be built up it’s just not
brittle in fact a very important psychoanalytic study of five people as I
recall it was done right after Dunkirk by a woman who at that point was not
married her name was Rosenberg then she became is Etzel and she looked at five
men that she worked with who were having the most problem after Dunkirk coming
off the beach they’re kind of readjusting and what she observed was
that these five men all told her that they had never felt fear in their life
until then and anybody who’s a dunker would have to understand fear but she
said people who had said yes I’ve been afraid before or you know I they were
more resilient than the people who said I never knew fear and she said there’s a
discipline illness in this and those people might have gone through life
never knowing fear and great but this isn’t the way to
a military and I think this is an important lesson and if we did some developed wise yeah it’s a good question you know the
militaries of every nation have often delved into this idea that we’re not
going to have that frankly one of my very one of my heroes said let’s not
take people who are truly you know mentally deficient people who have IQs
of 70 or less for example let’s not put them and you know why break people who
probably aren’t going to be able to cope in those circumstances but with those
exceptions there’s no way to predict how a person will really respond the United
States in fact in the British I want to read some British report where they want
to use a 19th century American way American Navy way of taking people who
wouldn’t be able to serve and successfully and it didn’t work I think
it never works there’s really no way to predict who’s gonna do well in World War
two again another hero of mine Harry stack Sullivan had this idea for
whatever reason that homosexuals shouldn’t go in the military not that he
was against homosexuals he himself was on the sexual but he for some reason
believed that they would break down and therefore it wasn’t a good idea to put
them there for their colleagues or for them or for the nation and in fact the
system that he developed and worked on very carefully proved not to predict who
would do well it kept thousands of people out of the war who later did go
to war when they finally said it’s enough we can’t do this anymore
and those people did as well as anybody else
there’s just no less than a history that predict who will do well who won’t but I
would say someone who clearly already has a psychotic disorder a severe
depression that doesn’t respond we now send people on medication for depression
into war but we don’t send people who are psychotic on antipsychotics into war
i it’s not a kindness and remember it’s not just a matter even you can say as a
matter of democracy and respect for people I do respect people who are who
have schizophrenia very much they lately tougher lives that most of
us will ever understand but the descendants of war would be totally
insensitive to their needs and would also be dangerous for the people around
them who depend on them not because they’re psychotic because they may not
respond well in that in that circumstance hi Derek McManus you
mentioned that there’s a lot of veterans children’s don’t need to service how did
I fare and how are they represented in the PTSD studies are they similar
percentages to the average population or do they have less – they’re not nearly
is enough is known I recently found myself on the board of above a new
program on the intergenerational legacies of trauma to try to understand
this and in fact there’s a much bigger literature on children of Holocaust
survivors all over the world quite a few here in Australia but the literature is
very mixed some of its seeming to show that people who were the children of
survivors of extreme trauma do better in life and some showing they have more
problems with anxiety or depression one of the more interesting findings I just
read recently and I think is a good insight is that they do better in life
until they run into a wall in which time they do worse in life there are a lot of
super achievers who have done extremely well in life were the children of
Holocaust survivors and I think of military members – but then if something
happens to them does that super achievement which itself may be a kind
of compensation it’s real you can’t pretend to be something special but if
something then says maybe you’re not special enough they may fall further
from a greater height but this is something we’re just need to
understand and almost nothing’s done we did a study because a medical student
wanted to do the study in history or medical school at Duke we looked at the
MMPI the Minnesota multiphasic personality inventory I do in fact of
which was brand new at that time of all kinds of psychiatric issues and we asked
Vietnam veterans to take PTSD scales and other kinds of scales depression
substitutes and we asked them to give to their children the same measure and we
wondered if the children would look like the parents and in fact they didn’t the
children and the children of parents with PTSD also didn’t look like their
parents on the other hand the children of people with PTSD had all kinds of
vaguely strange MMPI things they weren’t insane they weren’t damaged or but they
were different but there was no pattern by the way in the same way that people
often look at this sleep architecture of people with PTSD people PTSD don’t have
normal sleep architecture they don’t sleep normally but there’s no one
pattern to it and you know I think there’s a truth there about how people
adapt and it’s highly individualized it’s not as simple as we’d like it to be
if it were simply but it’s thought that we would have seen it and solve it by
now people need individualized approaches but that’s why I think so
many people who get this job done to do that individualized
if I can discontinue on the same vein what about the guys from guys and girls
from our Special Forces presumably there aren’t a high levels of stress higher
levels of just training environment and maybe see more traumatic events are they
higher represented in the the numbers of people with PTSD depression anxieties
no I you know there is some correlation between the severity of combat exposure
and the duration of combat exposure and developing PTSD it’s not as strong as I
said about social support the Special Forces people are highly selected and
they also have different experiences very often then they also have a lot
more support within their system where I see people this is just respond my own
experience deserve isn’t a good literature on this where I see them
running into trouble is later in life when they can no longer get access to
their buddies when they no longer can be functional at that elite level then
sometimes they become despondent because they’re you know they can’t they don’t
feel like themselves anymore and not only were they were they truly
exceptional people but they were honored and understood and in their roles they
performed exceptionally and there is oh I may not give them those opportunities
and that can be very challenging for them very soon we’re currently trying to
develop a welfare plan that basically means to best deal as we was taking
before Bevins doings saying you can’t just train someone and then training
programs well this is what we’re working on I wish I could say and it seems
perfectly laughing we would have fixed all this by now but but nobody have it
but this is where Paula Javitch and I and our colleagues in in Canada are
looking at buildings of systems if you asked what is the core of that system it
wouldn’t be something a doctor does it would actually be finding a way within
the military system to prepare people for leaving it from the time they enter
the system just the way that you know my medical school the Alumni Association
takes you for a barbecue before you ever start class and then they say to you
we’re doing this because you made it gets a long time but you’re going to
graduate and we want you to join the Alumni Association and we want to
support you in your role as a doctor when this happens the military should be
doing that from day one you know that you know if this is successful you might
have a 20 year career but you’re going to become a civilian quite frankly in my
experience when you meet even exceptional military people the one
thing that puts you know glazes over their eyes is when they anticipate
leaving the military because it’s like nobody who’s in the military has ever
left the military and it’s like what do I do
where do I fit what that can be that not plan can be developed the real core
though I think is is making sure that military members and their families know
what power they have to overcome these obstacles again either resilience is a
hard thing but they really do have power overcome these things frankly the Sesame
Street program we were on was one of the most important I think resilience
attitudes because it showed military families that yes you may have long
employments kids may not know what to do with their parents and parents may not
know what to do with their kids when they get back and besides like kids now
grown and doesn’t need the parent the same way and you know but but you’re a
family you’re gonna get through this and because you’re a family you’re gonna get
through this and you guys have what it takes to get through it that’s the
essential message and and I think that’s something that we have to find ways to
communicate and and and and roots to keep putting that into military culture
while people are in the military you know I can I am in awe of our
servicemembers and their families these are wonderful people who are doing
incredible things and and and the real pity is they don’t always realize their
own strengths they know their strengths in certain elements but they don’t
realize what they could accomplish in this particular mode so we have a lot of
work to do and I wish it had been done already well fine except some that’s good enough
to finish on the ones respect the senator whose families I think you’re
great lecture public right respondent makes you walk away full of questions
full of ideas very odd absolutely

1 Comment

  • Monish Kumar says:

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